1.1 ACO Composition and Governance Structure
The Lahey MassHealth ACO (LMH-ACO) is comprised of 16 primary care practice sites (122 individual providers). The ACO has contracted with both Tufts Public Health Plan (TPHP or Tufts Together) and Boston Medical Center Health Plan (BMCHP) to administer claims and manage membership.
LMH-ACO sits under the Lahey Clinical Performance Network (LCPN) and is governed by the Lahey MassHealth Advisory Council (MHAC), made up of three primary care providers (PCPs), two behavioral health providers, four hospital representatives, one patient advocate, and the ACO’s executive director and medical director. The Council includes 4 subcommittees (Quality, Funds Flow, Patient & Family Advisory Council (PFAC), and Operations).
1.2 ACO Population Served
The LMH-ACO is made up of approximately 10,400 members,1 residing in the northern and western suburbs of Boston up to the North Shore and Merrimack Valley area. Residents in Peabody, Beverly, Salem, and Lynn make up nearly 25% of total ACO membership. 30% of the ACO’s patient panel is attributed to PCPs located in Peabody and Beverly, and 36% is attributed to the Burlington Lahey Clinic. Other participating practices account for less than 10% of the ACO’s patient volume at any given site.
60% of the LMH-ACO’s members are Caucasian; 28% did not report race; 12% identified as Asian, Black, Hispanic, Pacific Islander, and/or Native American.
According to the MassHealth report compiled by Mercer that was sent to Lahey, the assigned ACO population is approximately 90% adults, with 50% of those in the RC IX category, 27% in RC 1 and about 15% in the RC II category. Nearly 30% of ACO members have a history of inpatient and/or outpatient SUD service utilization, with “poisoning by benzodiazepines” accounting for the fourth highest cost of all inpatient claims. Inpatient hospitalizations overall account for two-thirds of expenditures for this population, about 50% of which occurs at Lahey’s Burlington and Beverly hospitals. Boston Medical Center, Children’s Hospital, and South Shore Hospital account for a significant portion of inpatient expenditures among this population outside of the Lahey system.
The Lahey Data Analytics team is working with BMCHP and TPHP to refine the claims data and member demographics for the population assigned to the ACO as of March 1. As more data becomes available it is expected that the demographics and claims histories will provide the LMH-ACO with further detail on its patient panel, allowing for further development of strategies for care management, patient engagement, and integration of care.
1.3 Overview of DSRIP Investment Approach
1. ACO Programmatic Strategy
Population Health Management: LMH-ACO’s population health strategy is formulated by the ACO’s leadership and governing body. The execution of the strategy and functions will be a hybrid of centralized care management services with local site flexibility as needed to meet the specific population needs. Resources will be dedicated to addressing high complexity and moderate complexity patients, as well as prevention efforts.
Provider Accountability: The LMH-ACO Advisory Committee will determine how financial risk attaches to provider sites and/or individual providers, including which types of providers are exposed to incentive payments. At a minimum, both upside and downside risk will attach to the Lahey Clinic and Northeast Physician Groups, which will then have some discretion with respect to which type of risk attaches to individual providers. Total Cost of Care Management & Sustainability: The ACO’s population health strategy will provide improved care coordination to patients accounting for the top 5% and 10% of Lahey’s total cost of care (TCOC) in the Medicaid product line. Initiatives to reduce TCOC will include, but not be limited to, care management for the most complex and moderate risk patients, pharmacy efforts to transition patients from high cost brand name drugs to generics, Community Partner collaborations, and population health prevention programs.
2. Goals Supporting Overall Programmatic Strategy
The LMH-ACO has established a set of 10 goals spanning the domains of cost and utilization management, integration of physical, behavioral health, long term services and supports, social services, member engagement, and quality. These goals will help the ACO remain accountable for achieving meaningful change in care management, patient satisfaction, TCOC, and overall health outcomes for the MassHealth population. The LMH-ACO’s goals are tailored to realizing particular progress in the areas of mental health and addiction treatment, unnecessary acute care utilization, member engagement, and integration of care.
3. DSRIP Investment Strategy Supporting Achievement of Goals
The LMH-ACO’s DSRIP investment strategy is tailored to achieving success in meeting its goals over the 5 year performance period. Investments will be adjusted as necessary where improvement is not being realized on an annual basis (with state approval). The ACO’s governing body and related subcommittees, along with the ACO’s executive leadership, will be accountable for tracking performance against its goals and ensuring investments are prudent.
4. Anticipated Challenges
The LMH-ACO anticipates encountering challenges as it implements its strategy for improving care coordination, integration, TCOC accountability, and overall health outcomes. In particular, the ACO anticipates a relatively steep learning curve in incorporating community health workers (CHWs) into its care management programming, as well as potential physician hesitance about committing to some of the ACO’s 5 year strategic goals. The ACO has hired a nurse care manager with over a decade of experience with the MassHealth population, including overseeing pilots involving CHWs, to support Lahey in addressing the first challenge. The ACO’s leadership team will work closely with the governing body and subcommittees to foster a core set of physicians who will act as champions of the ACO’s goals among their peers.
Lahey’s IT department is currently building a LMH-ACO specific website within the Lahey website, which will include all required materials such as information on patient rights, grievance procedures, privacy protections, translation services, affiliated Community Partners, and participating PCPs.